Cape Town

The imposing Cape Dutch revival facade of Groote Schuur
Hospital, Cape Town, made a for a striking contrast to Mulago
Hospital, Kampala, where I spent four weeks studying Obstetrics and
Gynaecology. Inside, Groote Schuur had much in common with a London
hospital, but as I was soon to find out, it was the aetiology of
psychiatric presentations to the Emergency and Assessment wards
that would be so different to anything I would see at home. I chose
Cape Town for my psychiatry elective based on strong
recommendations from KCL students in the years above me. Most
patients speak English, making in-depth history taking and mental
state evaluation possible. High rates of HIV (17.8%) mean HIV
encephalopathy, dementia and psychosis are common presentations as
well as common mental health problems on a background of HIV. Tik
(methamphetamine) is widely abused in the community, resulting in
acute psychotic episodes, and hallucinogens are often prescribed by
traditional healers (sangomas) for relief.

This breadth of organic psychiatry, in the context of the great
socio-political challenges facing a post-apartheid nation made for
an irresistible opportunity to learn psychiatry in a brand new
context. My first day on the psych wards did not disappoint me. I
met a range of warm, friendly and fascinating patients, all with
unique stories to tell. One middle-aged gentleman had a twenty-year
history of schizophrenia but had recently been diagnosed with
Dandy-Walker malformation, with enlargement of the cerebral
ventricles and shrinking of the cerebellum. He presented with
cognitive deficits and worsening psychosis. The challenge was to
discern whether this was an incidental CT finding or an indication
of underlying neuropathology explaining his chronic illness. Next,
the psychiatrist covering A&E was called to assess a suicidal
twenty-year-old girl with learning disability secondary to foetal
alcohol syndrome. Typical of the tragic childhood stories of young
people from deprived backgrounds in South Africa, she had lost her
mother to TB (likely HIV-related) and her father to a road traffic
accident and was living in a township with a kindly woman (she was
not in contact with her siblings).

This lady had attended mainstream school late (because, after
their parents died, her sister forgot to enrol her), but her
learning disability was never commented on by teachers or assessed.
She became suicidal, she said, after one of her friends stabbed the
other and when she reported this to one of their mothers, she was
not believed. Attending A&E for this suicide attempt was her
first opportunity to access the learning disability and mental
health services available, which she had never been aware of
before. Finally, I met a lady in her sixties with worsening
persecutory delusions and self-neglect who was thought to have had
well-controlled chronic paranoid schizophrenia but was now
developing vascular dementia, confirmed by MRI. All three cases
were fascinating examples of the interface of psychiatry with
neurology and general medicine - and, on day one, affirmed to me
the importance of the psychiatrist as the doctor, who foremost,
must exclude organic pathology before proceeding to treat
psychiatrically. After such a rich first day, I can't wait to see
what the rest of my elective holds in store!

Cape Town is a beguiling city of immense beauty and horrendous
contrasts. More than any place I have ever been, there is a
sinister level on which you can live here, unaware of the suffering
going on around the corner. Drink a mojito with royalty on Camp’s
Bay, get your Maserati serviced, eat lobster with the rich and
famous – just don’t take a wrong turn down the N2 and end up in
Khayelitsha, or Gugulethu, or other evocatively named townships
like Brixton, Barcelona or Malibu Village. This is the legacy of
apartheid, in which Black and ‘Coloured’ families were uprooted
from their homes in the city, like the vibrant and now infamous
District 6, which was bulldozed to the ground.

These families were removed from the sight of ‘White-only’ areas
and relocated to hostels without basic amenities, or schools, or
healthcare. This explains why so much of the city’s deprivation and
destitution seems conveniently located out of sight of the Table
Mountain Cable Car, the Mount Nelson Hotel and the penguins on
Boulder’s Beach.

This is why the community clinics run by psychiatric registrars
and consultants within the townships are such an important part of
healthcare in post-apartheid South Africa. The majority of doctors
are White and there is a deep symbolism to the act of them
travelling into the townships (where they certainly do not live) to
diagnose and treat their patients. Here, listening to Afrikaans
questions translated into the magical clicks of Xhosa, was where I
observed truly holistic psychiatric medicine – and gained a small
sense of the deprivation in which the majority of Cape Town’s
residents live.

It’s not easy to take a psychiatric history with one or two
language barriers between you, the nurse interpreting and your
patient. A lot of the meaning of what you want to ask seems lost in
translation. And your cultural conception of their symptoms might
be different to theirs. While in Cape Town, most patients embraced
the medical model to a degree, and did not dispute the role
medication played in their recovery, it was not the only treatment
they sought. Many patients first looked to their sangoma
(traditional healer) for support and advice. Often, after little
success, the sangoma would refer them to mainstream services and
doctors even spoke of successfully working alongside a sangoma,
whose role was more one of social support than one of ‘healer’.

But other, less reputable members of this unregulated specialty
were known to prescribe hallucinogenic drugs which worsened
psychotic symptoms, or even advocate painful and disfiguring
procedures to ‘banish the demon’ to which they were attributed.
Psychiatrists in community clinics had to work together with the
patient’s cultural as well as religious belief system in order to
engage patients with a rather alien biological model of their
distress. The second enlightening aspect of community psychiatry in
Cape Town was the realisation that when statutory mental health
services are under-resourced, the burden of care lies truly with
the patient’s family.

The epitome of this overwhelming responsibility was encapsulated
by the predicament of Mrs F. She financially supported and cared
for her niece (since her sister had died), who had managed to stay
out of hospital despite many previous admissions for bipolar
disorder, and her daughter, who had learning disabilities. She also
supported her own children, one of whom caused her anxiety through
his involvement with knife crime in a local gang.

She had nursed her own mother until her death and then her
husband until his death from cancer. She worked nights cleaning
offices and spent most of her day taking care of the small,
meticulously well-kept flat she shared with her family in the
township of Athlone. My first thought was “when does she sleep?”
She doesn’t sleep much. You wondered how she coped with so much.
But as you looked around the lovingly polished photographs of all
these different children, siblings, nieces and cousins – you could
see exactly why she did it.

She knew that if she didn’t keep things together, many
inter-connected lives, held together so tenuously, would fall
apart. The extent of sacrifice and care Mrs F represented was
incredible to witness. But the enormous burden she bore, for which
she had previously been admitted to a psychiatric ward, took its
toll. Mrs F’s suffering was the result of deinstitutionalisation,
without the creation of community services to support the needs of
discharged patients. Her sacrifice was wonderful, but grossly
unfair. It was symptomatic of the historic abandonment of the
people of the townships – left to bear the social ills created by
the very regime that then refused to help. This was why it meant so
much that White doctors got in their cars and came to the clinics
and visited the houses of their patients – rather than staying
within the mansion walls of Groote Schuur.

Cape Town is a beautiful place. Surrounded on three sides by
dramatic coastline and stunning beaches, you can surf, scuba and
whale-watch (or cage dive) to your heart’s content. But when you
visit the Two Oceans Aquarium on the waterfront, look out for the
sign that tells you everything you need to know: “80% of Cape
Town’s children have never seen the sea.”

Organic psychiatry was what attracted me to an elective in Cape
Town and I was not disappointed. Differential diagnoses for
psychotic presentations included HIV or opportunistic cerebral
infections, temporal lobe epilepsy and tik (methamphetamine)
psychosis – the single largest mental healthcare burden on the
psychiatric wards. Tik is described as an ‘epidemic’ by
psychiatrists here because its use has exploded among the urban
poor of the townships. Methamphetamine can be easily manufactured
using basic items including ephedrine and ammonium fertiliser,
making it widely available (and commonly produced in rural farming
areas). Cheap, tik is described as ‘the poor man’s cocaine’, since
its effects last much longer. It is highly addictive and associated
with aggression, hypersexuality and violence – resulting in high
crime rates in communities already plagued by gangs, gun and knife
crime.

Most of the patients I met with tik psychosis were admitted for
their own or others’ safety, until they had recovered in about a
week. In others, however, methamphetamine formed the trigger for a
much more enduring psychotic illness, in some the starting point
for lifelong Schizophrenia. In Cape Town, tik played a role much
like that of cannabis in the UK: patients who became abstinent from
the substance recovered better, while those who returned to tik
abuse, widespread among their peers, tended to relapse.

On the neuropsychiatry ward (five beds in a city with 17.8% HIV
prevalence),I observed two unusual cases of psychosis and Multi
Drug-Resistant tuberculosis in young women who were HIV negative.
This presentation was unfamiliar to the team. After extensive
research, they considered the most likely cause to be a rare
neurotoxic response to Quinolone antibiotics prescribed for MDR TB.
Another woman on the ward had a more predictable picture of HIV
encephalopathy associated with an extremely low CD4 count.

What intrigued me about these cases was the clear need to treat
mental illness with physical therapy. In Britain, the law clearly
distinguishes between treatment of the mind and the body. The
Mental Health Act allows for treatment against a patient’s wishes
for a disorder of the mind, but not for one of the body. This was
upheld in a case where a patient with paranoid schizophrenia (Re:
C) was able to refuse amputation of his gangrenous leg, despite it
being life-threatening, because he had capacity to make that
decision about his physical health, however unwise. This leads to
difficulties with physical treatment (such as refeeding) for
psychiatric disorders (such as anorexia nervosa).

In Cape Town, there were so many possible organic aetiologies
for psychiatric presentations that doctors had to prescribe
physical treatment for psychiatric disorders, in their patients’
best interests. For example, in the many patients with depression,
psychosis or dementia directly attributable to their HIV infection,
the treatment simply was Anti-Retroviral Medication – and this is
what was prescribed. However, infectious disease specialists were
loath to commence ARVs in patients who lacked the insight to commit
to a life-long course, since the risks of non-compliance are
high.

Observing the practice of neuropsychiatry in Cape Town brought
home to me the inconsistencies in the mind/body dualism upon which
mental health legislation is founded. It may have its roots in
religious separation of the ‘soul’ from the body, or in Cartesian
traditions that reject the materialist view that mind and body are
one. But artificially separating the mind from the body prevents us
from seeing the whole person and encourages you to ignore physical
complaints when treating the mind or forget psychiatric concerns
when treating the body. I saw how this is potentially very
dangerous, clinically, not to mention, detrimental to the
relationship with a patient. It was exciting in Cape Town to
observe the genuine enactment of the oft-quoted buzzword, holistic
healthcare, as doctors considered every aspect of the individual in
their diagnosis, treatment and management.

All psychiatry in Cape Town was under-resourced, under-staffed
and under-funded, but this seemed to be most evident, or perhaps
just most upsetting, in Child and Adolescent psychiatry. An
excellent service is provided by the multi-disciplinary team of the
Red Cross Children’s Hospital, but more than anywhere else I saw,
they could only address the very tip of a very large iceberg.

The complexity of child and adolescent psychiatric need was
vast. This was unsurprising, in conditions of extreme poverty,
uprooting of family structures by premature death (often HIV, TB or
trauma-related) and economic migration – most patients did not know
their fathers and many were raised by extended family or friends.
Some of the need related to other issues I had already encountered
such as tik abuse, foetal alcohol syndrome and deprivation –
leading to dropping out of school and involvement with gangs. Other
problems were more broadly and complexly associated with the
violent history of South Africa and its current struggle to leave
its past behind.

In 2000, South Africa had the world’s highest per capita rape
rate, with one in three surveyed women reporting rape in the past
year. With a 40% lifetime risk, a South African woman has a higher
chance of being raped than completing secondary school. Rates of
sexual violence against babies and children are also extremely
high, with 67,000 reported incidents per year representing a
fraction of unreported abuse. It has been argued that one factor is
a widespread myth that sex with a virgin can cure a man of AIDS,
though its extent has not been quantified. The legacy of sexual
violence was evident among patients I met, and nowhere so
extensively as in child and adolescent psychiatry.

One thirteen year-old girl fortunate to receive extensive
multi-disciplinary treatment as an inpatient had psychotic
symptoms, low self esteem, obsessional traits, self harm, mood
disorder and dissociative symptoms, with a long history of sexual
abuse and inconsistent parenting. While her home environment was
unsafe, she spent her weekends there and often returned with much
of her progress undone after two days in the township. Poems she
wrote about the abuse she had suffered provided a small insight
into some of the trauma experienced at such a young age.

The team worked tirelessly with her challenging behaviour, to
support her as she went through puberty and tried to cope with her
childhood past – though still a child. Ultimately though, she was
to be discharged back into a violent, risky home environment –
since there were so many boys and girls just like her, in grave
need of one of the few inpatient beds available. The team did
amazing work with her, but it really was the tip of the iceberg.
The ability of the CAMHS team to work non-judgementally with
parents with as many social and psychiatric problems as their
children was truly powerful to watch.

I will never forget my four weeks in Cape Town and hope, as I
progress in Medicine, that I can make some small difference to the
enormity of the problem that exists below the surface of what can
currently be addressed. Organisations that extend some of the
benefits of healthcare in the West to assist sustainable
development will, I hope, work towards a world in which the scope
of care offered is not so unequal on the other side of the world.
My elective experience was one of contrasting frustration, sadness
and regret, with inspiration and even hope. I could leave each day
thinking how much more could be done with just a little more –
another psychiatrist, another clinic, a little more funding for a
few more psychiatric medications or psychological therapies. Or I
could leave thinking how much was achieved with so little, how
life-changing the treatment in the face of such unimaginable
deprivation, suffering and trauma.

Even on a more optimistic day, there was no denying the sheer
magnitude of inequality and plain unfairness of life in Cape Town –
and the Western Cape is the country’s most prosperous province.
How, as a doctor, do you get up each day and go to work in this
context?

The 19th century French quotation adopted as Valkenberg
Hospital’s motto stays with me, as I approach the start of my
medical career, in the magnificently privileged NHS environment.
Sometimes to cure, often to relieve, always to comfort.

About this blog

Roxanne Keynejad is a final year graduate
entry Medicine student at King's College London, having studied a
first degree in Psychology with Philiosophy at the University of
Oxford.

She is spending four weeks of her elective
studying psychiatry at Groote Schuur and Valkenberg Hospitals, Cape
Town, for which she received bursaries from the Royal
College of Psychiatrists elective bursary fund and the Institute of
Medical Ethics.